Is it safe to use cortisol (corticosteroid) cream on the eyes, especially for patients with a history of glaucoma or cataracts?

Corticosteroid Cream on the Eyes: Safety and Risks

Do not apply topical corticosteroid creams intended for skin use directly on or around the eyes, especially in patients with glaucoma or cataract history, as this poses significant risks of intraocular pressure elevation, cataract progression, and corneal complications. 1, 2, 3

Critical Safety Warnings from FDA Drug Labels

The FDA explicitly warns that prolonged corticosteroid use may result in: 2, 3

• Glaucoma with optic nerve damage
• Defects in visual acuity and visual fields
• Posterior subcapsular cataract formation
• Corneal and scleral perforation in patients with thin corneal or scleral tissue
• Masking or enhancement of ocular infections

Specific Risks in High-Risk Populations

Patients with Glaucoma History

• Corticosteroids increase intraocular pressure in 18-36% of the general population, but this rises to 46-92% in patients with primary open-angle glaucoma. 4
• Patients over 40 years, those with diabetes, high myopia, or family history of glaucoma are particularly vulnerable to corticosteroid-induced glaucoma. 4
• Steroids should be used with extreme caution in the presence of glaucoma, and IOP must be monitored routinely. 2, 3

Patients with Cataract History

• Posterior subcapsular cataracts can develop after as little as 4 months of topical corticosteroid use. 5
• The mechanism involves covalent binding of corticosteroid to lens protein with subsequent oxidation. 5
• The risk varies with dose and duration, with cataract incidence ranging from 11-15% with systemic use. 6

Safe Alternatives for Periocular Use

For Eyelid Eczema or Dermatitis

• Start with hydrocortisone 1% cream applied to eyelid skin (not ocular surface) twice daily for maximum 2-4 weeks. 7
• If inadequate response, switch to tacrolimus 0.1% ointment (0.03% for children 2-15 years), which has an 89% response rate for eyelid eczema. 7
• Never use tacrolimus if there is history of ocular herpes simplex or varicella zoster virus, as it increases susceptibility to herpes simplex keratitis. 1, 7

For Ocular Surface Inflammation

• Use preservative-free ophthalmic corticosteroid preparations specifically formulated for ocular use (dexamethasone 0.1%, prednisolone 0.5%, or loteprednol). 7
• Maximum duration is 8 weeks without ophthalmology co-management. 7
• Corticosteroids with poor ocular penetration (fluorometholone, rimexolone, loteprednol) may be less likely to cause IOP elevation or cataract formation. 1

Mandatory Monitoring Requirements

If ophthalmic corticosteroids are prescribed: 1, 7

• Measure IOP at baseline and within 1-2 days after initiation
• Perform pupillary dilation to evaluate for cataract formation
• Monitor IOP routinely if used for 10 days or longer 3
• Examine for corneal thinning, ulceration, or perforation risk

When to Refer to Ophthalmology

Mandatory referral before using any corticosteroid near the eyes if: 7

• Children under 7 years with periocular disease
• Moderate-to-severe disease requiring treatment beyond 8 weeks
• Any suspected ocular surface involvement or visual symptoms
• History of glaucoma or cataracts
• Treatment-resistant disease

Common Pitfalls to Avoid

• Do not use dermatologic corticosteroid creams on the ocular surface or conjunctiva - only ophthalmic formulations are appropriate. 1, 2, 3
• Do not continue topical corticosteroids beyond 8 weeks without ophthalmology co-management. 7
• Do not use preserved formulations near the eye - preservatives increase risk of allergic contact dermatitis and epithelial toxicity. 7, 5
• Do not use corticosteroids in the presence of corneal epithelial defects without ruling out infection first. 1
• Avoid in patients with active or history of herpes simplex keratitis unless combined with antiviral therapy. 1, 2, 3

Key Mechanistic Considerations

Only 5% of topically delivered corticosteroid is absorbed by the anterior segment, with almost zero distribution to middle and posterior segments. 6 However, small modifications in preparations can produce more than 20-fold differences in intraocular drug concentration, making formulation selection critical. 5